The havoc caused by the COVID-19 pandemic continues to disrupt daily life, but its reach goes deeper and further with mounting consequences for cancer patients who need ongoing treatment. Hospitals and clinics have shifted daily resources to cope with an influx of patients with COVID-19 disease, forcing cancer patients to weigh the potential benefit of a face-to-face visit and treatment with the risks of catching the virus.
The postponement of public screening programs, e.g. breast and cervical cancer has been widespread, reported by more than half of the 155 countries surveyed by the World Health Organization-the number of urgent referrals for cancer in England dropped by 60% in April compared with the same month last year.1, 2
The consequences of delayed diagnoses could be significant. An additional 6,270 cancer deaths have been predicted in Britain in the next year–a 20 percent increase–with an extra 33,890 deaths estimated in the US.3 One model predicts that in the US alone, reduced screening could mean delayed diagnoses for 80,000 cases of the five most common cancers in the three months ending June 5.4
The National Cancer Institute (NCI) says in a “conservative” model that deaths from breast and colorectal cancers, which together account for one-sixth of all cancer deaths, could rise by 1 percent annually in the US, or 10,000 per year, between 2020 and 2030 as a result of delayed diagnoses.5
Experts caution that these figures are subject to revision as the pandemic develops.
“We’re only talking about experiences based on the last three or four months, but we have no estimations if the curve picks up or if there’s a second wave of the pandemic.”
The NCI is particularly worried about cancers being detected at a later stage, requiring more aggressive and costly treatments, and worse outcomes.5
Early detection is crucial to treating cancer. In cervical cancer, for instance, the five-year survival rate is 92 percent if diagnosed before the cancer spreads, but just 17 percent when the cancer is at an advanced stage.6
During the COVID-19 pandemic, screenings have fallen sharply: Cervical cancer screenings were down 68 percent in the US across the first 15 weeks of 2020, while breast cancer monitoring fell by 17 percent, with bigger declines in areas where the outbreak was strongest.7
Rethinking risks and benefits
On top of missed opportunities to diagnose new cancers, fundamental questions about treatment have taken on a new, significant context in the pandemic. Some physicians must decide if preventing/treating COVID-19 should take precedence over cancer treatment, while patients must decide if the potential inherent risk should cause them to miss a treatment.
“I am used to witnessing primal fear, but I have never seen such widespread panic in my patient population as during the advent of SARS-CoV-2,” Mark A. Lewis, an oncologist in Utah, wrote in a recent article in the New England Journal of Medicine.8
“This is almost an impossible decision to make,” Dr. Devecseri said. “We need to think with an oncologist's mind; we need to imagine what's going on in a clinical practice, because no one can replace the treating physician who is standing next to the patient.
“Our responsibility is to give all the information about our drugs, to allow physicians to consider and assess and judge whether or not and how our treatments should be used.”
Such decisions, and their potential consequences, can impose a huge mental and emotional weight on both physicians and their patients.
“It's hard on patients,” she said. “They are not physicians and do not fully understand cancer, they don't fully understand COVID-19—but the doctors still need to work with their patients to make the best decisions.”
Adjusting to a new reality
The cancer community–people who currently have cancer, those whose disease is in remission or considered cancer-free, physicians, family members, caregivers and researchers–is taking steps to adjust. At-home treatment regimens are replacing some in-hospital procedures; clinical trials of new drugs, sometimes the only treatment option, have been modified to avoid infection; and the use of telehealth, which has soared during the pandemic, is maintaining a vital link between cancer patients and physicians.
Such coronavirus-driven workarounds could interfere with current protocols, but researchers are optimistic that some changes could be incorporated into future studies, such as the use of electronic consent signatures or direct shipping of oral medications to patients.
Telemedicine will need further refinement to be as effective as face-to-face evaluations, as oncologists often rely on subtle visual cues such as how a patient moves or whether they signal pain, which could be missed online.
“With telemedicine, you need additional questions and assessments, and you need to ask things differently—but this knowledge and methodology hasn't been developed yet,” Dr. Devecseri said. “Most of the time, we don't think about who these patients live with, how do they live, what is their daily life, do they need to go out, can they stay at home, what is the social network around them?”
It is a reminder that cancer patients cannot be defined only by their disease.
“What COVID-19 has brought, especially in the oncology community, is the need to think more about the patient's environment-oncologists don't really treat cancer, they treat patients. It's not just about the disease, but helping cancer patients live their life,” she said.
1 https://www.who.int/news-room/detail/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases, last accessed July 2020
2 https://www.bmj.com/content/369/bmj.m2386, last accessed July 2020
3 https://www.researchgate.net/publication/340984562_Estimating_excess_mortality_in_people_with_cancer_and_multimorbidity_in_the_COVID-19_emergency, last accessed July 2020
4 https://www.iqvia.com/insights/the-iqvia-institute/covid-19/shifts-in-healthcare-demand-delivery-and-care-during-the-covid-19-era, last accessed July 2020
5 https://science.sciencemag.org/content/368/6497/1290, last accessed July 2020
6 https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/survival.html, last accessed July 2020
7 https://knowledge.komodohealth.com/hubfs/white-papers/research-briefs/Komodohealth-covid19-2020-04-28.pdf, last accessed July 2020
8 https://www.nejm.org/doi/full/10.1056/NEJMp2006588, last accessed July 2020